Patient Family Advisory Council Application

Listening to patients and families is central to Plumas District Hospital’s approach to quality and improvement. The Patient and Family Advisory Council (PFAC) elevates the collective experiences of our community, supporting meaningful engagement in healthcare improvement efforts. In partnership with Plumas District Hospital, the PFAC serves as a key resource, offering insight that helps shape a better care experience for patients and families. Please fill out the application form below to apply.

Patient Family Advisory Council Application

First Name ^*

Please confirm your first name

Last Name ^*

Please confirm your last name

Email Address ^*

Please confirm your email address

Phone ^*

Please confirm your phone number

Languages Spoken:^*

Please enter any languages you speak

Yes

Please confirm the Mother's Full Name

Are you willing to share your contact information with other PFAC members? ^*

Yes

Please let us know if you will share your information

I/my family member has been treated at Plumas District hospital on:

Please let us know where you have been treated at PDH

I am the: ^*

Parent

Spouse

Caretaker

Patient

Other

Please tell us where you or your family member received care (Check all that apply):^*

Emergency Room

Medical Surgical Unit

Hospital/Swing Bed

Surgery

Outpatient Clinics

Laboratory/Imaging

Other Departments

Please tell us about any other care you received

Please tell us the activities you might be interested in: ^*

Improving the healthcare experience

Improving Patient Safety

Other projects/Interests (please explain below)

Other projects/Interests: ^*

Please let us know other interests, etc

Please tell us why you are interested in joining the Patient and Family Advisory Council:^*

Please let us know why you are interested

Please describe any other committee experience you have had either in schools, community, places of worship?^*
Please enter other committee experience.

Do you have experience with public speaking and are you comfortable speaking in front of people?^*
Let us know about your public speaking

Were there any situations where Plumas District Hospital helped make you or your family member's patient experience more comfortable?

Were there any situations where Plumas District Hospital contributed to you or your family member's patient experience being more difficult?

Please tell us the most convenient time for you to attend meetings?^*

Daytime

Evening

Patient Family Advisory Council Application